I wrote about the effect of every department wanting their own survey tool and the negative impact on experience from the staff’s perspective. I mentioned there that it also had a negative impact on patient experiences as well, but decided it was best left for a different discussion. On the heels of the essay on the impact of transactional relationships, it seemed a good time to revisit this topic.
Often, the act of surveying, at least as it is often presented to staff and sometimes patients, feels very manipulative, as it is outcomes-oriented. Not clinical outcomes, but survey outcomes. The conversation is not about improving experiences and having that translate into higher scores, but instead skipping the middle step and focusing on the conversation “what do I need to do to get you to give me a 9 or 10?”
CMS rules clearly state that you cannot ask CAHPS questions during a patient stay. You cannot ask patients to rate the nurses or doctors using the CAHPS questions and scale and you cannot tell a patient that you want them to give a 9 or 10 on the survey. I have seen hospitals dance around this rule by asking similar questions on a slightly different scale. I have also seen hospitals simply violate this rule, especially when it comes to the subject of 9s and 10s. Outside of the fact that breaking this rule can put you in CMS prison, I have never felt that this approach was very helpful.
Think about the last time you got your car serviced or engaged in any other consumer task that ended with someone saying, “You will get a survey and the only answers that matter are 9s and 10s, so please give me that or tell me now what I can do to assure that you will give us that score.”1 If you are like a lot of people, you probably have one of two responses to this request.
- You roll your eyes at the obvious game being played. You will either play along or not take the survey and either is good with the person asking.
- You find this to be a bit annoying. After all, if they spent as much time delivering excellent service as they do begging for 9s, they wouldn’t have to ask.
Either way, it feels performative. They need to make a show of trying to make you happy, even if they are not trying all that hard. It feels less like an effort to make something memorable and more like a reminder that they hope you got something memorable from this experience. The best-case scenario is that their heart is in the right place, but the consumer’s takeaway is likely that their training focused too much on talking the talk rather than walking the walk.
In healthcare, this especially feeds into this transactional relationship. One of the clinician’s most frequent complaints is that the survey process assumes that the patient knows what good and bad looks like in a hospital. While I will argue that it doesn’t, since it is asking about the experience and not the clinical decisions being made, the broad concern here is valid. The first iteration of the HCAHPS survey included a section on Communication on Pain. There was a gatekeeper question followed by two rating questions that were combined into an overall score. The questions were:
- “During this hospital stay, did you need medicine for pain?” (Y/N)
- “During this hospital stay, how often was your pain well controlled?”
- “How often did the hospital staff do everything they could to help you with your pain?”
These questions were removed in 2018 because there were concerns that by focusing on this element of an inpatient experience would lead to over-medication. While we can discuss whether this is an actual likely outcome or not, these questions did define in a patient’s mind what quality care looked like and created the assumption that good care should be pain-free.
Outside of the fact that this is, at best, a narrow definition of what good care is and the relative priority that pain management has in the list of care elements, this can assume that the relationship between patient and clinician is one of equals. None of this is true. Complete absence of pain is not always the best measure of clinical success and, as discussed in the previous essay, there is a power imbalance between patient and care team.
I am a firm believer in including patients into care decisions and that patients should get to make decisions about their care. But they are not experts on medicine, nor are they equal to the experts in this equation. They have a problem and they can be grasping at straws. They may not be in a good mental space of having a conversation about the difference between good pain and bad pain or focused on treating the cause and not the symptom. So, providing information and informed consent is critical, but giving a patient exclusive control over all care decisions is not. This creates a perception in the clinician’s mind that they are not healing a patient but merely giving the patient what they want and what a patient wants may not be clinical best-practice or even make clinical sense.
From the patient’s perspective, when they are told about the preferred answers to any survey questions, they often feel like the panhandling for 9s and 10s is the true objective in the care experience rather than the healing process. Some surveys, like HCAHPS, may be sufficiently removed from the interaction to not influence a patient’s perception of the care team’s motivation. It arrives a week or two later, so unless the patient is told by staff that ALWAYS and 10 are the only acceptable responses, it will feel like a distinct opportunity to share thoughts, whether that is an opportunity to celebrate the care, or, lodge a complaint.
But surveys are becoming more ubiquitous in care spaces. Hospitals are putting QR codes on everything and asking patients to rate the lab, imaging, food service, scheduling, etc. Some clinics are setting up kiosks at check-out, asking patients to score the clinic as they walk out the door. This is turning one hospital stay or clinic visit into a myriad of encounters, each to be evaluated in a vacuum. The challenge is that each of these encounters is a means to a broader end. Having a friendly imaging tech or phlebotomist is great. But if the overall hospital stay lacks coherence and teamwork, that smiling face means much less. By focusing on the space between needle-poke and the band-aid as “the lab experience” the patient compartmentalizes this and is less connected to the impact of this test on the care plan.
After my trip to the hospital, I was prepared for the fact that I would get five different bills, but I did not know that I would get four different surveys, one for the ED doctor, one for the outpatient procedure, one for the inpatient stay and one from the anesthesiologist. Since I saw the whole 40 hours as ONE event, telling me that it was actually four or five, did not make it easier to understand what happened or how to score it.
This is why I suggest that, if you want to know how patients feel about the food, don’t survey them. Ask them. Rounding on patients will give you more insights than a survey score. The reason why people would rather survey patients than talk to them is that the survey process feels more efficient and accurate. It may be more efficient, in that one can gather more survey responses than they can by rounding on patients, but is it accurate? It will be more consistent because every question will be asked of every patient, but that doesn’t mean that the questions are useful or that a patient will answer every one of them thinking about them in the same way you do. So, you may collect MORE data, but it also may be more BAD data. By surveying instead of talking, you have inserted a task between the patient and the staff member, and it becomes less satisfying for both.2
For me, though, the biggest problem with the insertion of a survey score request is that it breaks the spell of the interaction. Perhaps this sounds naïve or simplistic, but when I go get service, I expect that this interaction is based upon the business wanting to do the right thing for the customer. You want to deliver great service because you want me to come back, because doing a great job is easier than having to explain why you didn’t, because it is your job, because you enjoy what you do, because it is a highly-competitive marketplace. That motivation feels organic and understandable, even if I am being a bit moon-eyed.
Engaging with me—asking about my day, my needs, discussing options, establishing timelines—is how I see the process of delivering on good service. Asking me thoughtful questions shows me that you know what you are doing and that you really want to understand what is going on. Asking me about my day builds a personal connection and helps them find out if I am stressed and busy or relaxed, which will in-turn affect any conversation about timelines. But when you end the conversation asking me to deliver on a survey score, this breaks that spell. It feels like everything that preceded this request was not genuine, but simply an act to get something from me. You don’t really care about me; you care about a 10 on a survey. I am a means to an end and not an end in-itself. No one wants to be seen simply as a means.
1I had one person go one step further and told me not to take the survey if I could not give a 9 or 10. That really cut to the chase. I was amused that it did not even include the pretext of service recovery. “I am not going to even try to give you great service, so instead of trying, I will just tell you to suffer in silence.”
2Many people use surveys because they expect dissatisfaction and they don’t want to have to manage complaints face-to-face. But the reality is that most patients are happy with what they receive and by denying them the opportunity to talk to the staff member or manager directly to share the good stories, both the patient and the staff member miss out on a shared moment of joy.
PX Matters with Joseph Snipp 
Leave a comment